Starting in January, some Colorado residents’ health insurance will pay for in-vitro fertilization, but like many of the state’s efforts to expand coverage, it doesn’t apply to everyone.
House Bill 1008, which passed this spring, requires state-regulated employer health plans to cover the full range of infertility treatment services. People with other types of health insurance may have some coverage, but are more likely to have limits.
Here are answers to some common questions about the new law:
How will I know if this applies to me?
First, check your insurance card. If it says “CO-DOI” anywhere on the card, your insurance plan is regulated by the state. If not, the new mandate does not apply to you. This was also the case with other coverage requirements the state put in place in recent years, such as limits on out-of-pocket costs for insulin.
However, only large group plans regulated by the Colorado Division of Insurance fall under the new mandate. You can’t tell by looking at the card whether your insurance plan is large or small group, so you’ll need to call either your employer’s human resources department or your insurance company to make sure.
Religious organizations are allowed to ask their insurance plans not to cover certain fertility services they object to, but are required to notify employees if they do.
If you are covered by Medicaid or another form of government-provided insurance, the mandate does not apply to you.
I’m covered. What will she say?
Starting in January, you have coverage for fertility services that are considered appropriate according to the American Society for Reproductive Medicine guidelines. This may include preventive services, such as freezing eggs before a woman undergoes cancer treatment.
For people who need in-vitro fertilization, insurance will have to cover three egg retrievals and unlimited attempts to transfer an embryo. IVF involves stimulating the ovaries with drugs to produce more eggs, which are removed and fertilized outside the body with sperm from a partner or donor. They are then transferred into the body, hoping to result in a healthy pregnancy and birth.
Plans are not allowed to set limits on infertility drugs beyond what they have for other drugs, and they cannot set a special deductible or require higher out-of-pocket payments. However, this leaves room for variation: a family with a high-deductible insurance plan will almost certainly pay more out-of-pocket for infertility care than a family that pays higher monthly premiums in exchange for higher costs. low when using care.
The mandate uses the American College of Obstetricians and Gynecologists’ definition of infertility, which is the inability to conceive after one year of regular sex without contraception for women under 35 and six months without success for older women. It also allows coverage if a doctor diagnoses infertility in a different way.
My plan is not under mandate. Do I have any coverage?
Certain infertility services have been considered an essential health benefit in Colorado since 2017. This means that individual and small group plans must cover testing to diagnose infertility, as well as artificial insemination, without barriers or additional costs.
They should not cover IVF or egg freezing to prevent infertility. It’s not common, but some companies choose to add more infertility coverage, so check with your insurance provider before starting treatment.
It is possible for you to have additional coverage at some point in the future if the US Department of Health and Human Services signs off.
Why do only some plans need federal approval?
The Colorado Division of Insurance must decide whether any expansion of coverage constitutes a new mandate when it comes to state-regulated large group plans. It determined that the demand to cover more fertility services fell below the existing demand to cover maternity care.
For individual and small group plans, the US Department of Health and Human Services must agree that it is not a new mandate. Another bill calling for expanded fertility coverage passed in 2020 and sent the proposal to HHS for approval, but the department disagreed with the state and dropped it as a new mandate.
The 2022 bill essentially gutted state-regulated plans (which don’t require federal approval) to give some people coverage starting in January. The insurance division is still working to convince HHS that it should approve coverage of more fertility services for people with individual and small group insurance.